Preparing for Inspections

CQC inspectors have issued improvement notices where a practice website has been deemed 'out of date'.

What information should your website have?

Legal Requirements

1. Your CQC Inspection Rating:

From 1 April 2015, this too has been a legal requirement
CQC will assess whether or not your ratings are displayed legibly and conspicuously – not doing so may result in a fine and may impact on future inspection ratings.CQC's guidance around this matter is that "GP practices who have been awarded a CQC rating (Outstanding, Good, Requires improvement or Inadequate) must display it in their practice and on their website, where people will be sure to see it."To find out more about how and what to display CLICK HERE

2. Mean earnings for all GPs:

From1 April 2015, it has been a contractual requirement for practices to publish on their website the mean earning relating to the previous financial year for all their GPs and this needs to be completed by the end of the current financial year (ie 31 March 201X).

All earning reported should be before tax, National Insurance and employee pension contribution.

For GP partners, the figures should be net of any practice expenses incurred.

The BMA guidance has details of what income and expenditure to include and exclude when calculating the earnings for partners.

The rules around this are fairly detailed and partners may need their accountants to undertake the necessary calculations.

Cleanliness issues or just an untidy setup creates a bad impression and it is easy to become oblivious to this.

This problem is not dissimilar to moving into a new house and thinking that the first thing you will change are the bright purple carpets. Two weeks later you think that you will concentrate on doing the walls and change the carpets later. Six months down the line, other things have taken priorities and you almost don’t notice the bright purple carpets anymore, till someone visits and points them out to you.

Get your practice ‘Deep Cleaned’

A CQC visit is your chance to put your best foot forward. Cleaning up your surgery is no different to tidying up before a dinner party.If you don’t already use them, get a professional specialist cleaning service to ensure a thorough clean. Infection control walks hand in hand with cleaning. Ask your infection control lead to carry out a quick infection control audit so that nothing is missed.

Medical Fridges

Staff storing their sandwiches and other edibles in the medicine fridges.

Dirty and stained inside of fridge.

Fridge temperature logs not being maintained.

Make sure that nothing other than medicines stored in the medical fridge.

Clean out the inside of the fridge(s)

Ensure that your fridge monitoring temperature logs are available and discard any out of date medicines.

Medicines Management

Out of date medication

No date checking log being maintained

Medication ‘lying’ around in clinical rooms or patient accessible areas.

Also ensure that there are no medicines ‘lying’ around in clinical rooms or patient accessible areas.

Handy Hint: One thing that tends to get over-looked is out of date hand sanitizers

Notice Board

For our audits this is usually our first port of call.to see what things have been achieved, and how well informed your staff are. E.g. your Work place risk assessment pinned to the notice board gives assurance that not only have you conducted the Risk assessment but have ensured that staff are aware of the risks.

Out of date information displayed on posters

Old and tatty posters

Statutory and compulsory information not displayed

Public Notice Board Purge the notice public boards of all old and dog eared notices and replace with current information. Remember, one out of date poster undermines the relevancy of all other information.

Things that you may consider displaying are • Statutory notices (required by law) • Current employers liability insurance • Workplace Risk Assessment • Health & Safety Law Poster • Safe Working Practices poster • Manual Handling techniques poster • Fire extinguishers – what the different types are for and how to use them • Health and Safety Policy

Handy Hint: To save time, start using expiry dates on notices so that they can be binned when no longer relevant.

Staffing

The fear of an impending visit as it tends to stress out some people for fear of saying or doing the wrong thing on the day.

It has been our experience that some staff will even call in sick on the day, leaving you short-staffed.

Consider only informing key members of your team about the CQC inspection.

Staff

As part of our audits we spend a good portion of our time talking to staff. The reason for this is not to trip them up but to find out if anyone other than the Practice manager knows about the ‘policies and protocols’ of how the practice is to run.

When we talk to staff they often can’t remember or recall information.

Common reasons given are:

Can’t remember ever having an appraisal

Don’t know

I know the Practice manager told us about it, but I wasn’t really listening. (Our favourite reason)

Whilst we suggest that you might not want to tell all staff about the planned CQC inspection, do call everyone in for a staff session and go through short re-training sessions on essential items e.g.

Signing in procedures

Infection control

Hand Hygiene

Safeguarding

Confidentiality and IG Governance

Re-schedule Appointments

Doctors may have clinics and hence a limited time to spend withthe inspectors.

Re-schedule the appointments if you can to allow time for them to be able to answer and clarify things that other team members may not have as much knowledge of.

During the visit the CQC inspector will want to talk to the clinicians. Though most will wait to catch them during breaks etc. you might want to consider re-scheduling appointments for the day of the visit so that there is a clear break.

‘Difficult’ patients

Whether we admit it or not, we all have those ‘difficult’ patients that we’d rather were not present on the day of the inspection.This is not just about PR, but incidents can cause stress on the day and distract from an otherwise positive day.

Re-schedule their appointment, try and see them before or after the visit.

Confidentiality

Patient records lying around at reception and clinical rooms in easy access of other patients

Staff logging in using other’s log-in’s and/or passwords.

Ensure practice looks tidy and efficient, and that confidential records are not left lying around.

Love Bomb Patients

Many practice managers ask us how they are going to manage the few patients that an inspector is likely to talk to, as this handful may not be a true reflection of the 7500 patient list)

The easy answer is don't try managing this. If your practice is good, it will come straight from the patient.However, your staff can get into good practice by handing out patient information leaflets so that it becomes a habit and second nature.On the day of the inspection, inform the patients on arrival and maybe guide them on what they are likely to be asked and if they would like to volunteer.

Hand Hygiene

We regularly come across staff who do not sanitize hand, even after handling samples.

Get everyone to religiously sanitize their hands and disinfect touch screens at regular intervals.

Hand hygiene is not only a simple task to prevent infection and cross contamination but a visual reminder creating an impression that you take infection control seriously.

The Weakest Link

There is always one member of the team who does not know what to do because:

It is not their job

They have worked at the practice for 12 years and it was always done ‘that’ way.

Not paid enough to take on any responsibility

It is always someone else’s fault.

You are as strong as the weakest link.

If you have someone who is going to be letting the rest of the team down; other than it begging the question, ‘why are they still working for you?’

Get your evidence files in order

Keep visiting everythingCQC and find out what outcomes the inspectors are looking at.

Frequency of CQC Inspections from April 2018

CQC aim to reduce the frequency of inspections for GP practices rated Good or Outstanding to a maximum of every 5 years.

However, they may schedule a visit if:

CQC’s monitoring information indicates a change in the quality of care

A provider is part of a larger or complex provider, and a coordinated inspection alongside other services may be more appropriate.

CQC are undertaking a review of care services in a local area

Practices with a rating of inadequate or requires improvement will continue to be inspected as before.

Practices rated Good or Outstanding will need to provide annual information and data on overall performance; confirm how regulations are being met and declare any changes since the last inspection.

Good or Outstanding Practices

Maximum Intervals

CQC inspection

Five Years

Provider Information Collection

Yearly

Regulatory Review

Yearly

Interim Inspections

May be triggered based on information/concerns

Other requests for information

CQC relationship manager(s) may request further information if there are changes in the quality of care

Rated as Requires Improvement

Maximum Intervals

CQC Inspection

12 months

Provider information request

Before an inspection

Requests for other information

Relationship managers/Inspectors may request further information if there are changes in the quality of care

Rated as Inadequate

Maximum Interval

CQC Inspection

6 months (may be more frequent)

Provider information request

Before an inspection

Requests for other information

Relationship managers/Inspectors may request further information if there are changes in the quality of care

What is an Annual PIC?

Annual Provider information collection

Practices rated Good or Outstanding will need to provide annual information and data on overall performance; confirm how regulations are being met and declare any changes since the last inspection. (This information will need to be submitted via an online form.)

Practices with an overall rating of inadequate or requires improvement will continue to complete the provider information request before their inspection. PIR is a requests for specific information that will support your inspection.

Who will be targeted for inspections

CQC Inspectors are taking a targeted approach to selecting providers for inspection visits.

The CQC has confirmed that their primary targets will be:-

Practices judged as “Requires improvement” (Especially if weaknesses in SAFE and WELL-LED)

Your Insight Report shows underperformance or at risk

Information CQC has received e.g. whistleblowing, complaints, other reports

Recent changes in management e.g. Registered Manager

Recent changes in provider services

Where CQC have received notices of concern from the public or other sources

Additional targets

CQC are focused on patterns of poor performance in connected or related organisations.If you are part of a Corporate Group; Provider Group; Federation; Out of Hours member; GP Group then the following will flag you up for a potential visit:-

Others in your group show poor performance

Others in your geographical area show cause for concern

Inspection Team

Inspection Team

The inspection team will include the following:-

The lead CQC inspector

GP practices will always include a GP and may include other specialist inspectors, such as practice nurses and/or practice managers.

The team can vary in size, to reflect the size of the practice

May also include Experts by Experience

Note: GP Practices

From October 2015 the CQC is changing the way it organises its GP practice inspections, assigning a named lead inspector for each CCG area in a bid to improve the relationships between practices and inspectors.

The previous model, where the inspectorate identified CCG areas it would be focusing on and teams aimed to visit around a quarter of practices within a roughly four-week window, has been deemed inefficient.

What this means for practices:-

ProsRelationship building = better communicationGood practices will be able to avoid inspections - see Bowburn's experienceEmpathy with particular problems caused by demographics/pressures on the CCG causing issues

ConsIf you are a poor performer: Inspector will be more familiar and will target poor performers more easily

10 things to do to prepare for inspections

10 things to do leading up to the inspectionThere are very few people who would not feel any stress at all of an impending CQC visit when most GP practices will be given little or no notice before an inspection under the proposals for the new (yet again) inspection model.

We have been undertaking compliance audits for private clients for the last 8 years and based on this first-hand experience we have listed out below our recommendation for how you utilize this time to make your life as stress free as possible.

1. Get a ‘Deep Clean’ of your practiceWhen you know guests are coming over, do you go around and clean your house to make it perfectly presentable, or are you comfortable showing how you really live with no apologies? A CQC visit is very similar; it’s about putting your best foot forward.

If you don’t already use them, get a professional cleaning service who specialise in GP surgeries, to make sure that the practice is thoroughly spring cleaned.Infection control walks hand in hand with cleaning. Ask your infection control lead to carry out a quick infection control audit so that nothing is missed.

2. Medicines ManagementEnsure that your fridge monitoring temperature logs are available and discard any out of date medicines. Also ensure that there are no medicines ‘lying’ around in clinical rooms or patient accessible areas.

Handy Hint: One thing that tends to get over-looked is out of date hand sanitizers

Public Notice BoardPurge the notice public boards of all old and dog eared notices and replace with current information. Remember, one out of date poster undermines the relevancy of all other information.

Staff Notice BoardsFor our audits this is usually our first port of call.to see what things have been achieved, and how well informed your staff are. E.g. your work place risk assessment pinned to the notice board gives assurance that not only have you conducted the Risk assessment but have ensured that staff are aware of the risks.

Things that you may consider displaying are • Statutory notices (required by law)• Current employers liability insurance• Workplace Risk Assessment• Health & Safety Law Poster • Safe Working Practices poster • Manual Handling techniques poster • Fire extinguishers – what the different types are for and how to use them • Health and Safety Policy

Staff notice board also act as a good reference point on the day of inspection as staff are able to refer to information quickly and easily.

Handy Hint: To save time, start using expiry dates on notices so that they can be binned when no longer relevant.

4. Informing your staff about the CQC InspectionOnly inform the key members of your team about the inspection.

Try not to tell everyone about impending visit as it tends to stress out some people for fear of saying or doing the wrong thing on the day. It has been our experience that some staff will even call in sick on the day, leaving you short-staffed.

5. Staff MeetingWhilst we recommend that you shouldn’t be telling all staff about the planned CQC inspection, do call everyone in for a staff session and go through short re-training sessions on essential items e.g.

Signing in procedures

Infection control

Hand Hygiene

Safeguarding

Confidentiality and IG Governance

6. Reschedule AppointmentsDuring the visit the CQC inspector will want to talk to the clinicians. Though most will wait to catch them during breaks etc. you might want to consider re-scheduling appointments for the day of the visit so that there is a clear break.

Whether we admit it or not, we all have those ‘difficult’ patients that we’d rather were not present on the day of the inspection. . Consider re-scheduling their appointment, try and see them before or after the visit.

7. Love Bomb patientsAn easy way of getting patients on side is by giving out patient information leaflets over the 48 hours, and so that it becomes a habit, and on the day of the inspection if a patient is interviewed they have no reason not to know all about your practice and what services are available to them.

8. Hand HygieneGet everyone to religiously start sanitizing their hands and disinfecting touch screens. Helps create an impression that you take infection control seriously.

9. What to do with non-performing staff?You’re Only as Strong as your Weakest Link, is true of your organisation.If a member of staff is under a performance notice, or there is brewing dissent, it would be advisable to not have that member of staff on site. You can explain this to the inspector if the issue is raised.This is a good way to review your practices own attitude to staff. If you have someone who is going to be letting the rest of the team down, it begs the question, why they are working for you. We often get too close to staff, especially long standing staff, and lose sight of hard decisions about what's best for the practice and patients.

10. Get your evidence files in order

Editor's comment

A CQC inspector attending one of our seminars protested that some of the advice we give might be bordering on unethical because it encourages practices to game the system.This demonstrates the contradictory policies of the CQC. To observe 24/7/365 compliance, a true audit and inspection is one where the inspection takes place with minimal or zero notice. If the provider is given any prior warning, this is tantamount to giving licence to prepare and fix things before the visit. The longer that licence, the more lattitude you are giving.

CCGs are given 4 weeks notice of CQC inpections in their areas and GPs given 2 weeks' notice, if not more. As far as we know, only GPs are given this privillege, and this in effect skews the inspection heavily in favour of the provider, and is in itself an open licence to game the system.

In the real world, if you give advance notice of an audit or an inspection, you can expect the provider to make the best use of that time to prepare for the inspection. No reasonable and intelligent provider will freeze their activities and hang out the warts just so that an inspector has lots to report.

How much should it cost to prepare for CQC

The answer really depends on how much work you do on an ongoing basis to comply with CQC and what system you use to record your actions.

A survey by Pulse reported that practices had spent £10,000 on consultants just to prepare for CQC and cancelling up to 15 consultations on the day of the inspection.

"As a leading provider of CQC compliance systems, we find this ridiculous" says Bharat Patel, CEO of X-Genics. "A typical client of ours can generate evidence at the press of a button, a total of 20 minutes if you count printing time. Our typical consultancy charge to clients to prepare, if needed at all, is around £500, mostly to do with a pre-inspection review and helping compile evidence."

Level of preparedness

Compliance system used

External consultancy

Staff time

Preparing evidence

Stress Level

Totally unprepared

£250 to £500

Up to 10,000+

20 hours

30 hours

*****

Reasonably well prepared

£250 to £500

Up to £5,000

15 hours

20 hours

****

Mostly prepared

£500 to £750

Up to £2,500

10 Hours

15 hours

****

Fully prepared

£500 to £1,000

None

None

10 Hours

***

eManager Professional compliance system

£900+

None

None

20 minutes

**

Symptoms that you are not well prepared

If your answer to any of the questions below is YES, not only do you have a compliance problem, but your cost of preparation for CQC will be higher than it should be.

Understanding CQC

Your main priority is having all the policies and not daily monitoing

You will get around to reading KLOEs soon

Evidence

You have the paperwork but haven’t summarised results

You depend on staff having read policies

You have done the work but can't prove it on paper

Continuous Compliance

You only look at compliance every March to meet deadlines

You don't have regular safety checks

Monitoring

You don’t hold regular meetings

You hold meetings, but don't keep record of staff meetings

You don't keep a record of clinical meetings

You cannot poduce evidence of regular monitoring of standards

Systems used

You rely on a paper based system

You do not have a central collection of issues discovered

Get your focus right

Why? – Because for the last 20 years, PCTs and their predecessors have concentrated on folders holding all the policies. In most cases, this is what would have got you through a PCT inspection:-

Make sure all your policies have a current reviewed date

For any missing items, say that you have an action plan

Why? – Because the inspector’s job is to see if what you say you are doing, actually happens. Their main objective is to find out whether patients are looked after properly and their safety and rights protected.For an inspector, the best way to do this is:-

Interview your patients to see if they are happy with the service and whether they are kept informed about their treatment.

Interview your staff to see if they really do know what to do in particular circumstances.

Interview the Registered Manager to see whether they have a good handle on their duties

Look for evidence that you are monitoring activities, reviewing outcomes, and have regular quality assurance and clinical meetings to discuss and take action

Why? – Because getting things like training, implementation, and monitoring take far longer than what it sounds like on paper. Examples of practical problems that affect a manager’s time:-

Part time staff not being available at the right time

Some staff being slower at learning than others

Staff unwilling to take responsibility

Constantly running to keep on top of processes and paperwork

Everything is referred to the practice manager

All of these add up to a significant chunk of a manager’s time. Whether true or not, most managers will agree with the feeling that they spend more time shifting paperwork than actual management. So don’t underestimate the amount of effort and where your focus should be.

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Notice of Inspection

Beginning of the process

Prior to the inspection you will usually receive a letter of notification and an inspector will phone to confirm this and to confirm the date.

Although inspections can be unannounced, you should be given some notice for routine inspections, with GP Practices receiving two weeks' notice and the CCG getting four weeks advanced notice. Be careful though, CCGs have been known not to pass this down the line. Out-of-hours services will get 6-8 weeks’ notice as they have to prepare far more information.

Once these communications lines between you and the inspector are opened, the CQC will write to the practice for information required, and you can also ask for clarification and guidance on what needs to be prepared. GP Practices have five working days to respond to this request, out-of-hours have 10. If you are unable to produce everything, submit what you can within the deadline, and follow up with the rest as soon as possible.The inspection letter will also enclose “comment cards” and posters for display and distribution to patients on the day.

Questions CQC Inspectors ask your staff

These are the most common questions CQC inspectors usually ask your staff.

Can your staff answer these? Print this out and use as your checklist

1.1

How long have you been working here?

1.2

How did you apply for the job?

1.3

What it is that you do at the practice?

1.4

Do you have a job description/ clear role responsibility?

1.5

Do you have a contract?

1.6

Were you given a staff handbook when you joined or since?

1.7

Do you know where to locate the staff handbook?

1.8

Name one good thing you like about your work?

1.9

Do you have any concerns?

1.10

Do you feel supported?

2.1

How are you treated by the management and Partnership?

2.2

Did you have an interview when you applied for the job?

2.3

Were references taken when you were appointed?

2.4

Did you have a CRB/DBS check for the current position?

2.5

Do you have staff appraisal?

2.6

When was your last appraisal?

2.7

How did you follow up to the objectives & action plan set out in your appraisal?

3.1

Do you have regular meetings as a practice or individual?

3.2

Are you included in adding to the agenda?

3.3

Do you receive meeting minutes?

3.4

How are action points arising from the meetings followed up?

4.1

Do you know about vulnerable adults and children?

4.2

Who is the safeguarding lead at the practice?

4.3

What are the practices’ out of hours’ arrangements?

4.4

Are you aware of a whistle blowing policy?

4.5

Do you feel free to blow the whistle if and when necessary?

4.6

Do you know about the complaints procedure and can you describe it?

4.7

How do you react when you read NHS choices, if there is a complaint?

4.8

Have you received training?

4.9

What courses have you been on?

Provider Information Return ( PIRs)

Provider Information Return (PIRs)

This is what the CQC says they will normally ask for:

An action plan that addresses the findings from any patient survey carried out

A summary of any complaints received in the last 12 months, any action taken and how learning was implemented

A summary of any serious adverse events that occurred in the previous 12 months, any action taken and how learning was implemented

Evidence to show that the quality of treatment and services has been monitored. This includes evidence of two completed clinical audit cycles carried out in the last 12 months and evidence of any other audits, with evidence of actions or outcomes taken as a result

Recruitment and training policies and procedures (for example, how staff are recruited and vetted before commencing work, arrangements for European Economic Area (EEA) and foreign doctors and what induction they receive)

Number of staff by role (whole time equivalent)

A copy of the current Statement of Purpose

Keep a spare copy of what you send to the inspector, and don’t be surprised to find that when the team arrives they were not handed the documents you submitted.

Even if you haven’t been asked for in advance, you should anticipate at least the following:-

Significant event Audits

Infection control risk assessments and action logs

Cleanliness records, logs, and risk assessments

Review of disability access

Workplace Risk assessments, actions and outcomes

Fire safety reviews

Alarm test logs

Daily Safety checks and logs

Business continuity plan

Recruitment checks and evidence of induction process

Up to date policies and log of review dates

Safeguarding policies and evidence of training. Staff are likely to be interviewed on this.

Same for complaints and chaperoning

Medicine management, fridge logs, out of date medicines

Repeat prescribing procedures and controls

Training and recruitment logs

DBS checks

Equipment calibration reports

Staff training matrix

Questions CQC Inspectors ask your staff

These are the most common questions CQC inspectors usually ask your staff.

Can your staff answer these? Print this out and use as your checklist

1.1

How long have you been working here?

1.2

How did you apply for the job?

1.3

What it is that you do at the practice?

1.4

Do you have a job description/ clear role responsibility?

1.5

Do you have a contract?

1.6

Were you given a staff handbook when you joined or since?

1.7

Do you know where to locate the staff handbook?

1.8

Name one good thing you like about your work?

1.9

Do you have any concerns?

1.10

Do you feel supported?

2.1

How are you treated by the management and Partnership?

2.2

Did you have an interview when you applied for the job?

2.3

Were references taken when you were appointed?

2.4

Did you have a CRB/DBS check for the current position?

2.5

Do you have staff appraisal?

2.6

When was your last appraisal?

2.7

How did you follow up to the objectives & action plan set out in your appraisal?